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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1106764-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that facility staff persons did not properly document medication administration on a vulnerable adult’s (VA) medication administration record (MAR), that staff persons did not assist the VA with personal cares, that the VA wore soiled clothing and had “crusty” socks and feet with overgrown toenails, and that the VA had “caked” on feces in his/her genital area. Date of Incident(s): Prior to July 31, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 6, 2023; from documentation at the facility and from the VA’s medical records; and through nine interviews conducted with the VA’s case manager (CM), the VA’s guardian (G), a staff person from the VA’s day training and habilitation program (DTH), two facility managers (P1 and P2), three facility staff persons (P3-P5) and a facility health care professional (HCP). The VA did not provide information for the investigation due to his/her disability. Although this investigator contacted another facility manager (P6), P6 did not respond to requests to be interviewed. The facility kept medications for the VA in bins in a locked closet. The VA’s oral medications were delivered in bubble packs (a card containing doses of a medication for each day in separate sealed compartments) from the pharmacy. The VA’s Support Plan showed that s/he enjoyed walking, spending time with family and friends, and watching “planes land and take-off” at the airport. The VA was diagnosed with a moderate developmental disability. The VA’s Self-Management Assessment showed that the VA needed assistance with medication administration and that “support staff [persons] will ensure accuracy and assist [the VA].” Regarding staff persons not documenting the VA’s medication administration: P1 provided the following information: · Between January and June 2023, there was not a facility manager overseeing the facility site. · At some point in June 2023, P1 began overseeing the facility and upon review, determined that on several occasions, medications were not documented on the VA’s MAR, but were documented as given on the back side of bubble packs which was not the way that staff persons were trained to administer and document medications. Staff persons were trained, and retrained, to document administration of medications on the MAR. After staff persons took a class on medication administration, a program manager was supposed to observe staff person administering medications, but P1 did not believe that happened consistently. · At some point, P1 reached out to the HCP and asked him/her to go to the facility to conduct an assessment, but the HCP had not done so as of the date of the site visit, September 6, 2023. The facility had a Policy and Procedure on Safe Medication Assistance and Administration that provided the following information: · “When medication set up and/or administration has been assigned to the [facility] as stated in the person’s served Support Plan and/or Support Plan Addendum, staff [persons] who will set up or administer medications to persons served will receive training and demonstrate competency as well as reviewing this policy and procedure.” · “Upon completion of this course and prior to the setting up and/or administering medications, staff [persons] will be required to demonstrate medication set up and/or administration established specifically for each person served at their location, if this has not already been completed.” · Staff persons were to document if a dose of medication was not administered or treatment was not performed as prescribed, whether by staff person error, the client’s error, or by the client’s refusal. A review of the VA’s MARs from June to August 2023, by this investigator showed the following: · The VA was prescribed daily doses of alendronate for osteoporosis, aspirin, fexofenadine (an antihistamine), calcium, docusate sodium, and a weekly dose of atorvastatin to reduce cholesterol. · The June 2023, MAR showed staff person initials for all the VA’s prescribed medications on each date to indicate the medications were given except for alendronate on June 14, 21, and 28, 2023; aspirin and fexofenadine on June 12 and 14, 2023; calcium and docusate on June 12, 14, and 15, 2023; and atorvastatin on June 16, 2023. On those dates there were circles on the MAR and no initials. On the back of the MAR there was an entry for each date that stated that medications were given and there was a medication “error” that the MAR was not signed on those dates. · The July 2023, MAR showed staff person initials for all the VA’s prescribed medications on each date to indicate the medications were given except for alendronate on July 5 and 12, 2023; aspirin and fexofenadine on July 5, 17, and 27, 2023; calcium morning dose on July 5, 17, and 27, 2023, and calcium afternoon dose on July 4, 5, 6, 7, and 23, 2023; docusate morning dose on July 5, 17, and 27, 2023; and atorvastatin on July 23, 2023. On those dates there were circles on the MAR and no initials. On the back of the MAR there was an entry for each date that stated that medications were given and there was a medication “error” that the MAR was not signed on those dates. · The August 2023, MAR showed staff person initials for all the VA’s prescribed medications on each date to indicate the medications were given except for alendronate on August 2 and 23, 2023; aspirin, calcium, docusate, and fexofenadine on August 5, 8, 24, 30, and 31, 2023; and atorvastatin on August 16, 18, 20, 23, and 24, 2023. On those dates there were circles on the MAR and no initials. On the back of the MAR there was an entry for each date that stated that medications were given and there was a medication “error” that the MAR was not signed on those dates. The HCP provided the following information to this investigator: · If a staff person noted that a medication was not documented on the MAR, the protocol was for the staff person that discovered it to circle the box on the MAR, and then the staff person who was working that shift would be contacted to make sure that the medication was given. It was then expected that when that staff person was at the facility for his/her next shift, that s/he would add the documentation they missed on the MAR. · The managers were expected to check the MARs “multiple times throughout the week to make sure things are documented correctly.” The facility’s Internal Review provided the following information: · Shortly after P1 began working at the facility, s/he “gave all staff [persons] a verbal warning about documentation,” on August 1, 2023, and that “it was apparent that the medications had been passed as the bubble packs they came from had been initialed or lined up with the appropriate medication given from the last initial.” · On August 15, 2023, a staff person meeting was held to discuss “documentation errors.” · On September 3, 2023, P1 sent a “group message to all staff [persons]” stating that “written warnings would follow documentation errors.” P3, P4, P5, and a “fill in” staff person received “written warnings.” P3, P4, and P5 said that staff persons were instructed to document administration of medication on the bubble pack and on the MAR. P3 denied that there was an occasion when s/he did not document administration of a medication. P4 did not remember a time that s/he did not document when s/he administered medications. P5 acknowledged that there were occasions in which s/he did not document administration of medications on the MAR, but the medications were given to the VA. Regarding staff persons not assisting the VA with personal cares: The VA’s Individual Abuse Prevention Plan showed that the VA “has a tendency to wear clothes that are not clean or in good repair or will wear the same clothes [s/he] wore before and needs verbal prompts from staff [persons] to change [his/her] attire.” The plan also stated that the VA “doesn’t always wash and dry [his/her] whole body and may need verbal prompts to wash all areas of [his/her] body, completely rinse, and dry off [his/her] body.” The DTH provided the following information: · For the “past five or six months,” the DTH noticed that the VA had been periodically coming to the day program with “skin odor” and dirty clothing. When that happened, the DTH contacted someone at the facility, and sometimes the concerns were addressed and sometimes, they were not. · On July 31, 2023, the VA was incontinent at the day program and staff persons needed to assist the VA with showering. While assisting the VA to shower, staff persons noticed several areas on the VA’s body where it appeared that personal cares were not completed. The VA had long toenails, “crusty hard” socks, irritation on the VA’s skin, and what appeared to be dirt behind both the VA’s ears. The DTH stated that the problems seemed to stem from a lack of management oversight at the facility. Photos taken by the DTH on July 31, 2023, showed an area by one of the VA’s ears that appeared to have dirt or an abrasion and long and thick toenails on both feet with apparent dirt in between the toes. One of the VA’s toenails had blood with a toenail that was mostly detached. Photos also showed dirt in the VA’s shoes, two socks that appeared to be heavily soiled, and a reddened area on the VA’s buttocks. P1 provided the following information: · Shortly after P1 began working at the facility in June 2023, s/he noticed, and talked to the DTH regarding various concerns related to staff persons not assisting the VA with personal cares, specifically between January and June 2023. Some of those concerns included the VA having long toenails and “toenail fungus,” dirty clothing, and showing signs that s/he had not been regularly assisted with personal cares, such as showering. · P1 told staff persons to ensure that the VA’s dirty clothing was removed from his/her room so the VA would be less likely to wear soiled clothing. · Shortly after P1 began working at the facility, s/he took the VA to see a medical doctor and the doctor said to “make sure” that staff persons were “doing the creams that they were supposed to be doing.” On one of the VA’s medical visits in August 2023, P1 was told to assist the VA with soaking his/her feet daily. After the appointment, the VA’s feet were soaked as directed which helped the VA. P1 also contacted a podiatrist to have the VA’s toenails clipped and evaluated, but the appointment was not able to be scheduled until October 2023. · P1 felt that it was “evident” that staff persons had not been cleaning the facility because s/he found “feces caked on the toilet, floor, and walls.” In addition, when the VA was incontinent at the day program, it was noted that the VA had “caked feces” in his/her genital area, a “black substance” between the VA’s toes, and that staff persons did not assist the VA with showering. · P1 attributed the issues to the facility not having a “manager” for “so long.” P2 said that prior to P1 expressing some concerns in June 2023, related to the cares provided to the VA, P2 had not heard anything about the VA’s cares not being completed. P2 also stated that once concerns were raised, P2 worked with P1 and staff person meetings were held to discuss some of the concerns and to set up corrective actions plans, such as taking dirty laundry out of the VA’s bedroom and assisting the VA with picking out clean clothes to wear each day. P2 stated that “one of the problems” was that several staff persons from other facility locations worked various shifts at this facility location. P3 provided the following information: · When staff persons asked the VA to take a shower, the VA “never” said, “No.” When P3 assisted the VA with taking a shower, which was to be done daily, P3 set clean clothes out on the VA’s bed and then assisted the VA with taking a shower. P3 said that s/he assisted the VA with a washcloth and soap, and washed all parts of the VA’s body. When the shower was done, P3 assisted the VA with drying off his/her body before putting clean clothes on. At some point in May or June 2023, P3 noticed that the VA’s toenails were “super long.” P3 informed someone about that, but s/he did not remember who. · When P3 was asked to describe how the facility addressed the VA’s dirty clothes, s/he stated that the VA’s laundry basket was taken from his/her bedroom on Sundays. If there were occasions when P3 saw the VA wearing the same clothes more than one day, P3 encouraged the VA to change clothes. P4 stated that staff persons were to assist the VA to take a shower every other day. P4 was not aware of a time that the VA’s personal cares were not completed. P4 also stated that although there were times that the VA wore dirty clothing, P4 verbally encouraged the VA to change clothes when that happened, and the VA was usually cooperative with doing so. P4 stated that the VA’s dirty clothes were to be removed from his/her bedroom daily. P5 stated that staff persons were to assist the VA with a shower three times weekly. When the VA took a shower, staff persons needed to physically wash and clean all areas of the VA’s body. P5 stated that s/he had been told that the VA was able to independently shower, but P5 did not know who told him/her that. P5 also stated that s/he checked the VA’s bedroom daily to remove any soiled clothing and that the soiled clothing was washed the same day. P5 was not aware of any issues with the VA’s toenails. The facility’s Internal Review provided information that was mostly similar with the information provided in interviews with P1, P3, and P5, and the following additional information: · On an unspecified date, P1 held a staff person meeting with unspecified staff persons in attendance. During that meeting, staff persons stated that they were “aware” of the VA’s health needs and that the issue was “likely due to simple laziness from staff [persons].” P1 stated that P5 and two other unnamed staff persons “seem to be adequately assisting” the VA with his/her personal needs and cares and that the “primary issue with cares not being done is likely from staff [persons] that are assigned to other programs in the company who pick up shifts” at the facility and “fill holes in the schedule.” · P1 planned to “implement a list of personal cares needing to be done and will follow up” with staff persons on “the list being completed each night” with assistance from P2. · When P5 was interviewed, s/he stated that s/he “checks” the VA’s genital area for “redness every shift” s/he worked and that s/he also “orders more cream” for the VA, as needed. P5 stated that s/he provided hand over hand assistance to the VA when assisting the VA with showering and ensuring that his/her body was dry after the shower before assisting the VA with putting on clean clothes. However, P5 thought that there were occasions when the VA wore the “same clothes” when P5 was not working. P5 had not noticed an issue with the VA’s toenails. · When P4 was interviewed, s/he stated that s/he assisted the VA with showering, drying, and putting on clean clothes. P4 attempted to trim the VA’s toenails, but the nail clipper at the facility was “not strong enough” to do so. P5 thought that fill in staff persons might not have assisted the VA with showering or personal cares and that it might be due to “lack of knowledge about how to complete the cares properly or simple laziness.” · When P3 was interviewed, s/he stated that s/he assisted the VA with showering and recently, began assisting the VA with “taking foot baths” and applying “antibiotic ointment” after the VA’s feet were dried completely. P3 also stated that s/he did not assist the VA with cleaning his/her genital area “unless” the VA asked for assistance, but that s/he had not observed any redness or rashes on the VA. P5 thought that fill in staff persons “may not assist” the VA with personal cares or showering and that some fill in staff persons “may not be fully aware of the resident’s needs.” The G stated that the VA needed “verbal reminders” and staff person assistance to complete personal cares. The G also stated that when s/he visited the VA at the facility on unspecified dates, the VA’s bedroom had a mixture of clean and dirty clothes on the floor. The G stated that over the past number of months, there had been meetings held to discuss the concerns and the G was “frustrated” because the “excuse” from the facility was that the issues stemmed from “short staffing.” The CM stated that over the years, the VA’s ability to care for him/herself had declined and that currently, staff persons were expected to provide “hand over hand” assistance with showering and personal cares. The CM also stated that the VA needed verbal reminders to wear clean clothing. In addition, the VA frequently got “rashes” on his/her skin, it was expected that staff persons ensured that the VA was dry after showering and that various “creams” were applied to the VA’s skin. The VA’s medical records, dated August 3, 2023, stated that the VA was seen by a medical doctor for “toes, feet, groin, rash behind ears and forehead” and a “skin check.” The VA was diagnosed with balanitis (inflammation of the skin in the genital area) and “skin sores.” The VA was prescribed “topical bacitracin” on the back side of the VA’s ears. In addition, the VA was to receive miconazole cream on the VA’s genital area, two times daily (the VA’s MAR for August 2023 showed that this was previously ordered by a medical doctor as a PRN medication, but another section of the MAR indicated that the medication had previously been prescribed and was to be given two times daily. Within the August 2023, MAR, there were blank marks and circles related to this medication). Medical records, dated August 23, 2023, showed that the VA was seen for “toe pain/problem” and was diagnosed with “nail avulsion of toe.” Although the records did not indicate a treatment plan, P1 stated that direction was given to soak the VA’s feet daily and to seek guidance from a podiatrist (scheduled for October 2023). The VA’s MAR for June to August 2023, showed the following: · The June 2023, MAR showed that on Mondays, Wednesdays, and Fridays, staff persons were supposed to “clean” and “assist [the VA] with cleaning” the VA’s genital area. Daily, the VA was to have warm compresses to both eyes for two minutes. There were no staff person signatures next to any dates for either of these tasks. Staff persons applied a PRN cream to the VA’s genitals, as indicated by initials on the MAR, on 14 days, and applied a powder for “rash” on 7 days. · The July 2023, MAR showed that the VA was to shower daily, to brush his/her teeth twice daily, have a warm compress to both eyes daily for two minutes, have staff persons “check and assist” with cleaning his/her genital area three times a week, and have staff persons “check and trim” nails monthly. The MAR showed that the VA showered on 16 days, the VA brushed teeth twice daily on nine days and once on seven days, had warm compresses applied on eight days, had staff persons check and assist with genital area cleaning on three days, and the VA’s nails were checked once. The VA had a PRN powder applied for “rash” on five days. · The August 2023, MAR showed that the VA was to shower daily, brush his/her teeth twice daily, have a warm compress applied to both eyes daily for two minutes, have staff persons “check and assist” with cleaning his/her genital area three times a week, and have staff persons “check and trim” nails monthly. The MAR showed that the VA showered 29 days, the VA brushed teeth twice daily except for one day, warm compresses were applied to the VA’s eyes on 22 days, staff persons checked and assisted the VA with cleaning his/her genitals on six days, and the VA’s nails were checked and trimmed once. On August 23, 2023, soaking the VA’s feet in Epsom salt daily and applying bacitracin to the VA’s left middle toenail were both added to the MAR and completed one day. The facility’s Position Description for P3-P5 showed that some of their duties included the following: · “Provide direct care/support services to individuals supported as well as written in their Community Service Support Plan (CSSP), CSSP-Addendum, or any other relevant service plan in the areas identified.” · “Provide clear, concise, and timely documentation of all services provided.” The facility’s Position Description for P6 stated that some of his/her duties included to “provide supervision and oversight to the assigned programs in accordance with the responsibilities assigned to the Designated Manager in 245D,” and “ensure that the delivery and evaluation of services are coordinated by a Designated Coordinator and that these duties are fulfilled for assigned programs/services according to the individuals CSSP, 245D, the Positive Supports Rule, and other applicable requirements.” P6 was also supposed to “ensure staff [person] competency requirements are met, and staff [person] orientation and training are provided according to chapter 245D and the Positive Supports Rule requirements.” The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans. In review of the facility’s personal records, it was also noted that P3 had one hour of training on medication administration in June 2023, P4 had one hour of training related to “documentation” on December 15, 2022, and medication administration training on November 16, 2022. P5 was trained on documentation and daily living skills in 2022 and medication administration in June 2021. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.05, subdivision 1, stated that the license holder was responsible for meeting health service needs assigned in the support plan or the support plan addendum, consistent with the person’s health needs. Minnesota Statutes section 245D.05, subdivision 2, paragraph (c), clause (6), stated that the license holder must ensure that when a medication was administered it was documented in the person’s medication administration record. Minnesota Statutes, section 245D.081, stated that the license holder was responsible for coordination of service delivery and evaluation for each person served including program management and oversight by having a designated staff person who must provide supervision, support and evaluation of the license holder’s responsibilities assigned in the person’s support plan and addendum; instruction and assistance to direct support staff persons implementing the support plan and the service outcomes; and direct observation of service delivery to assess staff person competency. Conclusion: A. Maltreatment: Information showed that between January and June 2023, the facility did not have a management staff person directly working in the facility and overseeing staff persons and the VA’s care. In June 2023, P1 began providing oversight at the facility and noticed several instances in which medications were not documented on the VA’s MAR as administered but had been documented on and missing from the bubble packs so were likely given to the VA. The VA’s MARs from June to August 2023, showed several dates that medications were not initialed as given which was a violation of Minnesota Statutes section 245D.05, subdivision 2, paragraph (c), clause (6). In addition, P1 noticed that staff persons had not been routinely assisting the VA with personal cares, washing the VA’s clothing, and performing cleaning duties at the facility. The VA had long, bloody, and torn toenails, body odor, and wore soiled clothing on several occasions. The VA’s June 2023, MAR showed that on Mondays, Wednesdays, and Fridays, staff persons were supposed to “clean” and “assist [the VA] with cleaning” the VA’s genital area. Daily, the VA was to have warm compresses to both eyes for two minutes. There were no staff person initials next to any dates for either of these tasks to show they were completed. The VA’s July and August, 2023, MAR showed that the VA showered on 16 days, the VA brushed teeth twice daily on nine days and once on seven days, had warm compresses applied on eight days, and had staff persons check and assist with genital area cleaning on three days. The rest of the days did not have staff person initials to indicate these things were completed which was a violation of Minnesota Statutes, section 245D.05, subdivision 1. The DTH had concerns that the VA was not assisted with personal cares. On July 31, 2023, the DTH provided information and photos that showed “caked feces” in the VA’s genital area, a “black substance” between the VA’s toes, an area by one of the VA’s ears that appeared to have dirt or an abrasion, long and thick toenails on both feet with one mostly detached bloody toenail, dirt in the VA’s shoes, two socks that were crusty and heavily soiled, and a reddened area on the VA’s buttocks. The VA’s Individual Abuse Prevention Plan showed that the VA “has a tendency to wear clothes that are not clean or in good repair or will wear the same clothes [s/he] wore before and needs verbal prompts from staff to change [his/her] attire” and “doesn’t always wash and dry [his/her] whole body and may need verbal prompts to wash all areas of [his/her] body, completely rinse and dry off [his/her] body.” The VA’s Self-Management Assessment showed that the VA needed assistance with medication administration and that “support staff will ensure accuracy and assist [the VA].” The VA relied on staff persons to prompt and assist him/her with personal cares including showering and wearing clean clothes. In addition, staff persons were supposed to ensure the VA received medications as prescribed. Although it’s likely the VA received medications and staff persons did not document correctly, given that the VA showed physical signs that cares were not being completed including having sore, “caked” feces in his/her genital area, a bloody broken toenail, black substance on his/her toes and behind his/her ear, and “crusty” soiled socks and shoes, that the June and July MARs showed that the VA was not showered, assisted with cleaning his/her genital areas, and other treatments not completed, there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Between about January 2023 and June 2023, the facility was without a program manager to oversee operations and ensure that the VA’s personal cares were consistently completed. Multiple staff persons were involved in the failures to provide necessary care and services to the VA. Over the course of six or more months, there were multiple staff persons involved in the failure to provide necessary care and services to the VA with no staff person acting as a facility designated coordinator or manager which was in violation of Minnesota Statutes, section 245D.081 and represented a systemic failure to provide the VA with reasonable and necessary care and services. Therefore, it was determined that individual staff persons’ responsibility was mitigated, and the facility was responsible for the maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious because the VA did not have injury that required the care of a physician. Action Taken by Facility: The facility completed an Internal Review and determined that although policies and procedures were adequate, they were not followed (the review did not specify what was not followed). The review also stated that “all” staff persons, particularly staff persons “picking up shifts” would be retrained on the VA’s specific care plans. Action Taken by Department of Human Services, Office of Inspector General: On August 29, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which the facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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